Download Gingival Diseases in Childhood- A Review

Global Journal of Medical Research: J
Dentistry and Otolaryngology
Volume 14 Issue 3 Version 1.0 Year 2014
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals Inc. (USA)
Online ISSN: 2249-4618 & Print ISSN: 0975-5888
Gingival Diseases in Childhood- A Review
By Dreshan Verma, Apurv Jhawar, Navreet Khinda & Drmeena Anand
Manipal College of Dental Sciences, Manipal, India
Abstract- Children are exposed to various gingival diseases, similar to those found in adults, yet
differ in some aspects. These diseases could be plaque or non-plaque induced, familial, or may
be associated with a systemic condition. It is crucial to diagnose and manage gingival diseases
as early as possible as they have the potential to further progress, causing a severe breakdown
of periodontal support. Consequently, the final result may lead to tooth loss at an early age,
which in turn will affect the nutrition and overall development of a pediatric patient. Therefore,
greater emphasis is given to the prevention, early diagnosis, and treatment of gingival disease in
children. As a dentist, it is necessary to be able to distinguish and differentiate all possible
gingival conditions to successfully manage them. By establishing excellent oral hygiene habits in
children, which will carry over to adulthood, the risk of periodontal disease is lowered. This paper
will review various gingival conditions that are found in children, their main clinical features and
management.
Keywords: gingival diseases in children, plaque induced gingivitis, non-plaque induced gingivitis,
early diagnosis, pediatric gingivitis.
GJMR-J Classification: NLMC Code: WU 600
GingivalDiseasesinChildhood-A Review
Strictly as per the compliance and regulations of:
© 2014. Dreshan Verma, Apurv Jhawar, Navreet Khinda & Drmeena Anand. This is a research/review paper, distributed under the
terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http://creativecommons.org/licenses/bync/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Gingival Diseases in Childhood- A Review
Dreshan Verma α, Apurv Jhawar σ, Navreet Khinda Ρ & Drmeena Anand Ѡ
Keywords: gingival diseases in children, plaque induced
gingivitis, non-plaque induced gingivitis, early diagnosis,
pediatric gingivitis.
eriodontal disease may have its origins in
childhood. Studies confirm a high prevalence of
gingival inflammation in children, which may
progress to periodontitis, resulting in the loss of primary
and permanent teeth. Therefore, promptly diagnosing
and treating gingival diseases in childhood may reduce
the risk of carrying forward the disease in adulthood.
Gingival diseases affecting children may be broadly
classified into Dental Plaque- induced and Non-plaqueinduced gingival diseases (table 1).1
Table 1 : Gingival Diseases: Classification
Table1- Gingival Diseases: Classification
Dental Plaque-induced Gingival Diseases
A. Gingivitis Associated with Dental
Plaque Only
I.
Without local contributing
factors:
• Chronic gingivitis
• Plaque-Induced gingival
enlargement
II.
With local contributing
factors:
• Eruption gingivitis
• Mouth breathing
• Crowding gingivitis
• Gingival Changes Related to
Orthodontic Appliances
Non-plaque-induced Gingival Diseases
A. Gingival diseases of Viral origin
• Primary Herpetic
Gingivostomatitis
B. Gingival diseases of Fungal origin
• Acute Candidiasis (Thrush,
Candidosis, Moniliasis)
• Linear gingival erythema
C. Gingival diseases of Bacterial origin
• Acute necrotizing ulcerative
gingivitis (ANUG)
• Streptococcal infection
(Catarrhal gingivitis)
D. Congenital gingival Anomalies
• Congenital gum synechiae
• Congenital epulis
Author α: Tutor, Department of Prosthodontics, Manipal College of Dental Sciences, Manipal University, India. e-mail: [email protected]
Author σ: Intern, Manipal College of Dental Sciences, Manipal University, India. e-mail: [email protected]
Author ρ: Final year student, Manipal College of Dental Sciences, Manipal University, India. e-mail: [email protected]
Author Ѡ: Associate professor, Department of Periodontology, Manipal College of Dental Sciences, Manipal University, India.
e-mail: [email protected]
© 2014 Global Journals Inc. (US)
2014
Introduction
Year
P
I.
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Abstract- Children are exposed to various gingival diseases,
similar to those found in adults, yet differ in some aspects.
These diseases could be plaque or non-plaque induced,
familial, or may be associated with a systemic condition. It is
crucial to diagnose and manage gingival diseases as early as
possible as they have the potential to further progress,
causing a severe breakdown of periodontal support.
Consequently, the final result may lead to tooth loss at an early
age, which in turn will affect the nutrition and overall
development of a pediatric patient. Therefore, greater
emphasis is given to the prevention, early diagnosis, and
treatment of gingival disease in children. As a dentist, it is
necessary to be able to distinguish and differentiate all
possible gingival conditions to successfully manage them. By
establishing excellent oral hygiene habits in children, which will
carry over to adulthood, the risk of periodontal disease is
lowered. This paper will review various gingival conditions that
are found in children, their main clinical features and
management.
Gingival Diseases in Childhood- A Review
B. Gingival Diseases Modified by
Systemic Factors
I.
Associated with the
endocrine system:
• Puberty gingivitis
• Diabetes Mellitus associated
gingivitis
II.
Associated with blood
dyscrasias:
• Leukemia associated
2014
gingivitis
Year
•
III.
18
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E. Traumatic Gingival Lesions
• Factitious gingivitis
• Accidental
• Iatrogenic
F. Gingival lesions of genetic origin
• Hereditary gingival
fibromatosis
G. Foreign body reaction
• Amalgam tattoo
H. Gingival manifestations of systemic
conditions (rare)
•
Others
•
Pemphigus vulgaris
Associated with nutritional
deficiency:
•
•
Kindler syndrome
Lichen planus
Ascorbic Acid Deficiency
Gingivitis
•
Allergic reaction
•
Wegener's Granulomatosis
I.
Gingival Abscess
C. Modified by medications
I.
Drug-induced gingival
enlargement
Modified from Armitage GC: Development of a classification system for periodontal
diseases and conditions, Ann Periodontol 4:1, 1999
Gingiva of children is different in many aspects.
Gingiva of the primary dentition generally appears as
pale pink, but less pale than that of an adult.2 The
marginal gingival is also more vascular and contains
fewer connective tissue cells.3 The thinner, more red
appearingepithelium with a lesser degree of
keratinization may be interpreted as mild inflammation.3
The width of attached gingiva is less variable in the
primary dentition, causing fewer mucogingival
problems3; however, the width increases with age.4
Stippling in children usually appears at about 3 years of
age without significant inter-arch difference.5 Interdental
papilla is broad bucco-lingually and narrow mesiodistally.6 The junctional epithelium tends to be thicker of
the primary dentition than the permanent.7Gingival
sulcular depth ranges from 1-2 mm which is
shallowerthan that found in adults.8
There are normal physiological changes
associated with tooth eruption that may appear as
agingival pathology and must be distinguished. The
gingival prominence caused by the crown of an
underlying erupting tooth is firm and pink, with mild
inflammation from mastication; however an eruption cyst
will presents as a bluish or deep red enlargement of the
gingiva over the erupting tooth6. The gingival margin of a
newly erupted tooth appears rounded, edematous and
reddened and may mimic gingivitis. This paper will
present various dental plaque and non-plaque induced
gingival diseases affecting children and adolescents.
© 2014 Global Journals Inc. (US)
II.
Dental Plaque-Induced Gingival
Diseases
Chronic gingivitis is common in children and
adolescents, where inflammation is generally limited to
the marginal gingiva with undetectable loss of bone or
connective tissue attachment6. The primary cause is
dental plaque related to poor oral hygiene.6Clinical
features include red linear inflammation, increased
vascularization, swelling, and hyperplasia9. Bleeding
and increased pocket depth are found less frequently in
children than in adults, but may be observed in severe
gingival hypertrophy or hyperplasia.9 Calculus deposits
are rarely seen in infants but may increase with age6;
however, children with cystic fibrosis have higher
incidences of calculus, which may be caused by
increased
salivary
calcium
and
phosphate
concentrations10.
Plaque control procedures11 in the primary
dentition can be accomplished by rubber-cup coronal
polishing (if no calculus is evident) or by selective supragingival scaling (if calculus is evident); however as
permanent teeth erupts, additiontargeted sub-gingival
scaling may also be necessary. Oral hygiene measures
should be instructed to parents and children in terms
that both understand. The dynamic process of
developing manual dexterity impacts the ability of a child
to perform expected procedures. Children are
encouraged to use a simple scrub technique; more
III.
Non-Plaque Induced Gingival
Diseases
Primary herpaticgingivostomatitis is an acute
infectious disease of the gingiva caused by
herpessimplex viruses (HSV) Type-1 most commonly
affecting children between 2-5 years of age.28Clinical
features include febrile illness, headache, malaise, oral
pain, mild dysphagia, and cervical lymphade-nopathy
3,9,13,28,29
. Gingivitis is the most striking feature, with
markedly swollen, erythematous, friable gums3,13,29 The
© 2014 Global Journals Inc. (US)
Year
Diabetes mellitusType 1 occurs more frequently
in children and adolescents than Type 2. Gingival
inflammation and periodontitis are more prevalent and
severe in affected children with poor metabolic control
than in unaffected individuals.20 Premature tooth loss
and impaired immune response to oral flora occurs in
severe cases. Treatment includes- controlling diabetes,
disease prevention21 and early training and motivation of
children to maintain efficient plaque control21, 22.
Leukemiais the most common type of cancer in
children, and acute lymphoblastic leukemia is the
commonest amongst them. It is accompanied by oral
symptoms that include acute gingival enlargement,
ulceration, bleeding and infection.23 These patients have
low tissue-resistance to infection, owing to decreased
circulating leukocyte count, which is further complicated
by cytotoxic drugs (interfere with epithelial cell
replication) that are used in the treatment of leukemia.
Therefore, rigorous plaque control measures must be
implicated both before commencing cytotoxic treatment
and during medical treatment.22,24
associated
with
vitamin
C
Gingivitis
deficiencycan lead to edematous and spongy gingiva,
spontaneous
bleeding,
and
impaired
wound
healing.12The underlying deficiency must be corrected,
along with plaque control.12
Drug-induced gingival enlargementcan occur in
children
taking
anticonvulsants
(phenytoin,25,26
26
valproate ), calcium channel blockers (nifedipine26,
diltiazem26, verapamil26), and immunosuppressives
(cyclosporine A27). Although complicated by increased
plaque along the gingival margin, t features of this
condition differ from that of chronic marginal gingivitis.9
The clinical features are very similar irrespective of the
drug involved. The first signs of change usually appears
3 to 4 months after drug administration. Enlargement
appearsmulberry-shaped, pink, firm and stippled in
patients with good hygiene, however, in subjects with
pre-exiting gingivitis, or a poor standard of plaque
control, the enlarged tissues shows classical signs of
gingivitis3. To manage such enlargement, strict oral
hygiene instructions and scaling must be implemented.3
Severe cases inevitably need to be surgically excised
and re-contoured (gingivectomy and flap surgery).3 A
follow-up program is essential to monitor plaque control
and to detect any recurrence, in which case drug
modification may be needed.3
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refined brushing techniques can be introduced during
adolescence. Flossing should be added to the home
care routine as interdental contacts develop, and is
usually not indicated in the primary dentition stage.
Antimicrobial mouth rinses for chemical plaque control
are not indicated in very young children because of the
risk of ingestion.
induced
gingival
enlargementPlaque
occursdue to prolonged plaque exposure which may be
complicated by local factors like mouth breathing, or
orthodontic appliances.12 Clinically, it ranges from pale
and fibrotic to red and friable.12 There is localized or
generalized enlargement of the interdental papilla and/or
gingival margin.12 Meticulous plaque control is required,
and sometimes, gingivectomy or gingivoplasty may be
indicated.12
Eruption gingivitisis a temporary type of
gingivitis seen in young children during teeth eruption.13
Tooth eruption itself does not cause gingivitis; infact it is
the inflammation associated with plaque accumulation
around erupting teeth is common7. Eruption gingivitis is
usually mild which requires no treatment other than
improved oral hygiene.13
Mouth breathingand lip incompetence may
result in increased plaque and gingival inflammation
which is often limited to the gingiva of the maxillary
incisors due to frequent drying out of the gingiva.11, 14
Treating the cause of mouth-breathing may resolve the
problem for example gingivitis secondary to mouth
breathing caused by allergic rhinitis can be treated by
antihistamines6 and incompetent lips can be corrected
by orthodontic treatment.
Crowding gingivitisis due to irregular arrangement of the dentition, preventing self-cleansing of the
mouth. It is worse in children who do not brush their
teeth regularly. Oral hygiene instructions and
orthodontic treatment can alleviate the gingivitis.11
Gingival changes due to orthodontic appliances
can occur within 1 to 2 months of appliance placement
due to difficult plaque removal.11 Changes are generally
transient, rarely producing long-term damage to
periodontal tissues.11 Use of special toothbrushes (e.g.
powered tooth brushes) and additional cleaning tools
may be recommended for better plaque control15.
Pubertal gingivitispeaks at 9 to 14 years of age
and generally subsides after puberty.7 Hormonal
changes during puberty accentuates the vascular and
inflammatory response to dental plaque9 and also alters
reactions of plaque-microbes16 that could explain this
modified gingival response. Frequently, it presents as
enlargement, bleeding and inflammation in interproximal
areas without concomitant increase in plaque levels
affecting both males and females.17 It generally
subsides after puberty however severe cases are
treated by improving oral hygiene13, removing all local
irritants13, restoration of carious teeth13 and improving
nutritional status (e.g. administration of 500mg of
ascorbic acid orally for 4 weeks19).
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Gingival Diseases in Childhood- A Review
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Gingival Diseases in Childhood- A Review
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goal of treatment isto make the patient comfortable, and
to prevent secondary infections or worsening systemic
illness. Supportive management involves bed rest,
eating a soft diet, and maintaining adequate hydration
and treating pyrexia using paracetamol suspension.3,29
Secondary infection of ulcers is prevented using
chlorhexidine.3 Systemic treatment includes antivirals
(acyclovir) and analgesics (acetaminophen). Topical
anesthetics may also be used; however, do not speed
healing.3,13,29
Candidiasisis caused by candida albicans
following a course of antibiotics or as a result of
congenital or acquired immunodeficiences. In neonates,
infection can be contracted during passage through
vagina. It is less common in children and is rarely
associated with a healthy child.30 It presents as raised,
furry, white patches, which if removed leaves bleeding
underlying surface.13 Infants can be treated topically by
a suspension of 1mL (100,000 U) of nystatin 4 times a
day. Older children can be treated using clotrimazole
troches or nytatin pastilles. Severe cases can be
managed by systemic fluconazole (infants-suspension
6mg/kg or less per day; older children- 100mg tablet for
14 days).13 Catarrhal gingivitis (streptococcal gingivitis)is
caused by hemolytic streptococcus. Clinical features
include fever, headache, myalgia, and arthralgia31. The
gingiva is painful, appears red, soft and friable, and tend
to bleed spontaneously. Improved oral hygiene,
mouthwashes and antibiotics are recommended for
treatment.31.
Acute necrotizing ulcerative gingivitis (ANUG) is
a broad anaerobic infection caused by fusiform bacteria,
spirochetes, and other gram-negative anaerobic
organisms.3.29,32 Malnutrition, stress, lack of sleep are
few predisposing factors.29,32 It is common in young
children in less-developed countries. ANUG is rapid in
onset and very painful. “Punched out” ulceration and
necrosis occur in the interdental papillae and marginal
gingival,
covered
by
yellowish-grey
pseudomembranous slough.3 Eventually, involve the alveolar
crest and may progress to necrotizing ulcerative
periodontitis in immuno-compromised individuals as
recurrence is inevitable. Treatment include intense oral
hygiene, professional plaque removal, mouthwash rinse
(0.5% hydrogen peroxide -removal of necrotic tissues
and 0.2% chlorhexidine- prevents plaque formation),
antibiotics (penicillin or metronidazole), and NSAIDs for
pain.33
Congenital epulisis a rare gingival tumor that
occurs along the alveolar ridge in newborns, without
additional congenital malformations or associated teeth
abnormalities. Clinically presents as a smooth, welldefined erythematousmass arising from gum pad. Small
lesions may regress and larger lesions must be
resected, as they often interfere with airway and cause
feeding difficulties. The un-erupted teeth are not
affected usually.34
© 2014 Global Journals Inc. (US)
Congenital gum synechiaepresents as unilateral
or bilateral adhesions between the maxilla and mandible
in the form of fibrous bands that makes feeding,
swallowing and respiration difficult soon after birth. Early
treatment is recommended which involves excision of
alveolar bands. If not treated, it may result in TMJ
ankylosis, restricted jaw growth and overall growth may
also be affected (restricted feeding).
Traumatic lesionscan be factitious, iatrogenic or
accidental and can occur as a result of chemical
physical or thermal injury.37 Toothbrush abrasion due to
faulty brushing technique is very common which
presents as painful ulceration with surrounding
erythematous halo. These may usually get superinfected
by normal mixed flora of oral cavity when these ulcers
may get covered with yellowish exudates.33 Initial
professional cleaning followed by cessation of toothbrushing for 7-10 days is recommended, during which
child should rinse 2 times daily with 0.1%
chlorhexidine.33 The right brushing technique must also
be taught to the child.
Factitious gingivitis (Gingivitis artefacta) is a
self-inflicting physical injury of gingiva that could be
habitual, accidental or psychological in origin.3, 38The
minor form is caused by rubbing or picking of the
gingival with fingernail or abrasive foods while, the major
form is more severe and widespread, involving deeper
periodontal tissues.3 Other areas of the mouth may be
involved, as well as extra-oral injuries found on the
scalp, face or limbs. Management includes removal of
irritation source, habit correction, and wound
dressings.3,38 In major cases, psychological or
psychiatric consultation may be advised.3,38 Hereditary
gingival fibromatosis is a rare overgrowth usually
transmitted as dominant trait40. Enlarged gingival tissues
are usually normal, pink, firm and leathery with little
inflammation and involves attached, interdental and
marginal gingiva.39,40,41 There may be esthetic or
functional problems, such as mal-positioning of teeth,
prolonged retention of primaryteeth and delayed
eruption of permanent successors.41 In addition, the
hyperplastic regionproduces conditions favorable for
accumulation of dental plaque causing secondaryinflammatory changes.41 Treatment include removal of
hyperplastic tissues by conventional gingivectomy.42
Strawberrygingivitisis gingival manifestation of
Wegener’s Granulomatosis, a necrotizing granulomatous vasculitis affecting upper and lower respiratory
tract and kidney44 which may also affect pediatric age
group45.
Oral manifestations include the gingiva
exhibiting erythema and enlargement,typically described
as
“strawberry
gums”.43,46
Treatment
include
administration of immunosuppressives like prednisolone
and cyclophosphamide 43, 44 for which child patient must
be referred without delay for medical evaluation and
management43.
Gingival Diseases in Childhood- A Review
IV.
Conclusion
To summarize, the differences in the causation
and pathogenesis of gingival diseases in children are as
varied as their adult counterpart with similar clinical
presentations of gingival bleeding, pain and swelling.
Nevertheless the importance of recognizing these
gingival manifestations in childhood can give a clue
towards an underlying pathology like nutritional
deficiency, immunological disease or even a leukemic
state. Therefore the thorough knowledge of gingival
diseases in childhood and their treatment contributes
not only towards better oral care but also augments a
comprehensive general pediatric care of the individual.
References Références Referencias
1. Armitage GC: Development of a classification
system for periodontal diseases and conditions,
Ann Periodontol 4:1, 1999.
2. Maynard JG Jr, Ochsenbein C: Mucogingival
problems, prevalence and therapy in children, J
Periodontol 46:543-543, 1975.
3. Richard R. Welbury, Monty S Duggal and M.T.
Hosey. Paediatric dentistry 3rded (2005); oxford:
periodontal diseases in children: pg 231.
4. Andlin-Sobocki A: Changes of facial gingival
dimensions in children. A 2-year longitudinal study,
J ClinPeriodontol 20:212-218, 1993.
5. Bimstein E, Peretz B, Holan G: Prevalence of
gingival stippling in children, J ClinPediatr Dent
27:163-165, 2003.
6. NewMan ,Takei, Klokkevold, Carranza. Carranza's
clinical periodontology volume 1, 11tthed; gingival
diseases in childhood: pg 143.
7. Bimstein E, Matsoon L: Growth and development
considerations in the diagnosis of gingivitis and
periodontitis in children, Pediatr Dent 21:186-191,
1999.
© 2014 Global Journals Inc. (US)
Year
9. Oh Tj, Eber R, Wang HL: Periodontal Diseases in
child and adolescent, J ClinPeriodontol 29:400-410,
2002.
10. Wotman S, Mercadante J, Mandel ID, et al: The
occurrence of calculus in normal children, children
with cystic fibrosis and children with asthma, J
Periodontol 44:278-280, 1973.
11. Clerehugh V, Tugnait A: Diagnosis and
management of periodontal diseases in children
and adolescents, Periodontol 2000 26:146-168,
2001.
12. American academy of Pediatric Dentistry; The
handbook of pediatric dentistry 3rded; periodontal
diseases and conditions: pg 68.
13. Ralph E.McDonald, David R. Avery Jeffery A.Dean.
Dentistry for child and adolescent; 8thedMosby:
Gingivitis and periodontal diseases: pg 413.
14. Van Gastel J, Quirynin M, Teughels W, Carels C.
The relationships between malocclusion, fixed
orthodontic appliances and periodontal disease. A
review of the literature. AustOrthod J 2007, 23:121129.
15. Borutta A, et al. Effectiveness of powered
toothbrush compared with a manual toothbrush for
orthodontic patients with fixed appliances, J Clin
Dent 2002;13(4):131-7.
16. Demir T, Orbak R, Tezel A, Canakc V, Kaya H: The
changes in the T-lymphocyte subsets in a
population of Turkish children with puberty gingivitis,
Int J Paediatr Dent 19:206-212, 2009.
17. Sutcliffe P: A longitudinal study of gingivitis and
puberty. Journal of Periodontal Research 1972
7:5258.
18. Modeer T, Wondimu B: Periodontal diseases in
children and adolescents, Dent Clin North Am
44:633-658, 2000.
19. Cohen MM. The effect of large doses of ascorbic
acid on gingival tissue at puberty, J Dent Res
34:750-751(abstract), 1955.
20. Pinson M, Hoffman WH, Garnick JJ, Litaker MS:
Periodontal disease and type I diabetes mellitus in
children and adolescents, J ClinPeriodontol 22:118123,1995.
21. Lalla E, Cheng B, Lal S et al: Periodontal changes in
children and adolescents with diabetes: a case
control study, Diabetes Care 29:295-299, 2006.
22. Meyle J, Gonzáles R: Influences of systemic
diseases on periodontitis in children and
aldolescents. Periodontology 2000 26:92-112, 2001.
2014
8. Srivastava B, Chandra S, Jaiswal JN, et al: Crosssectional study to evaluate variations in attached
gingiva and gingival sulcus in the three periods of
dentition, J ClinPediatr Dent 15:17-24, 1990.
21
J ) Volume XIV Issue III Version I
Global Journal of Medical Research ( D
Kindler syndrome is an autosomal recessive
disorder47 that may present with oral lesions that are
clinically consistent with desquamative gingivitis, along
with Cutaneous neonatal bullae, poikiloderma,
photosensitivity, and acral atrophy.48 Traditional nonsurgical periodontal treatment can be beneficial for
treating gingival menifestations.47
Pericoronitisis inflammation of gingival covering
partially erupted tooth (most commonly third molars).12
Food entrapment creates an ideal environment for
bacterial growth leading the pericoronal flap to become
inflamed and swollen.12 The enlarged flap, traumatized
by occlusion, is very painful. Debridement, chlorhexidine
irrigation and antibiotics are used for management.12
Gingival abscessis an acute, localized, painful
lesion of marginal gingiva or interdental papilla, caused
by anembedded foreign objects.12 Treatment is done by
debridement, drainage and chlorhexidine irrigation.12
Year
2014
Gingival Diseases in Childhood- A Review
Global Journal of Medical Research ( J ) Volume XIV Issue III Version I
22
23. Abdullah BH, Yahya HI, Kummoona RK, et a;:
Gingival fine needle aspiration cytology in acute
leukemia, J Oral Pathol Med 31:55-58,2002.
24. Wahlin Y-B: Changes in oral microbiota, mucosal
lesions and salivary secretion in patients with acute
leukemia. Thesis Umeå, 1990.
25. Dahllöf G: Phenytoin-induced gingival overgrowth in
epileptic children. A clinical, histological and
biochemical study. Thesis. Stockholm, 1986
26. Hallmon WW, Rossmann JA: Role of drugs in the
pathogenesis of gingival overgrowth, Periodontol
2000 21:176, 1999.
27. Daley TD, Wysocki GP, Day C: Clinical and
pharmacologic correlations in cyclosporine-induced
gingival hyperplasia, Oral Surg 62:417,1986.
28. Sapp JP, Eversole LR Wysocki GP: Contemporary
oral and maxillofacial pathology, ed 2, St. Louis,
2004, Mosby(Elsevier).
29. NewMan ,Takei, Klokkevold, Carranza. Carranza's
clinical periodontology volume 1, 11tthed; Acute
Gingival infections : pg 138.
30. Blyth CC, Chen SC, Slavin MA, et al: Not just littler
adult:
candidemia
epidemiology,
molecular
characterization and antifungal susceptibility in
neonatal and pediatric patients, Pediatrics
123:1360-1368, 2009.
31. Edgar David Coolidge, Maynard Kiplinger Hine.
Periodontology, clinical pathology and treatment of
the periodontal tissues; catarrhal gingivitis: pg 188.,
Lea 1958.
32. Sabiston JR: A review and proposal for the etiology
of acute necrotizing gingivitis, J ClinPeriodontol,
13:727-734,1986.
33. Koch G, Poulsen S: Periodontal conditions, pg 180,
Pediatric Dentistry A clinical approach ed 2, 2009
Wiley-Blackwell.
34. Bernadette L. Koch, Charles Myer III, and John C.
Egelhoff. Congenital Epulis; AJNR April 1997: 18
35. Haydar SG, Tercan A, Uckan S, Gurakan B.J.
Congenital gum synechiae as an isolated anomaly:
a case report. ClinPediatr Dent. 2003; 28(1):81-3.
36. Mohammad Ghasem Shams, Mohammad HoseinKalantarMotamedi and Hassan LalDolat Abad.
Congenital fusion of the maxilla and mandible: brief
case report. Oral Surg Oral Med Oral Pathol Oral
RadiolEndod 2006;102:e1-e3.
37. NewMan ,Takei, Klokkevold, Carranza. Carranza's
clinical periodontology volume 1, 11tthed;
classification of diseases and conditions affecting
the periodontium: pg 62.
38. Dilsiz A, Aydin T: Self- inflicted gingival injuries due
to habitual fingernail scratching: a case report with a
1-year follow up. Eur J dent. 3(2):150-154, Apr 2009.
39. NewMan ,Takei, Klokkevold, Carranza. Carranza's
clinical periodontology volume 1, 11tthed; Gingival
enlargements: pg 123.
© 2014 Global Journals Inc. (US)
40. Anderson J, Cunliffe WJ, Roberts DF, Close H:
Hereditary dingivalfiberomatosis, Br Med J
3(5664):218-219, Jul 26,1969.
41. Sho L. yamamoto. periodontal disease: symptoms,
treatment and prevention; nova biomedical books
New York (2011): periodontal diseases in children
and adolescent: clinical features and molecular
biological analysis: pg31.
42. Ramer M, Marrone J, Stahl B, Burakoff R: Hereditary
gingival fibromatosis: identification, treatment,
control. JADA 127:493-495, Apr 1996.
43. Chee HK: Wegener’s Granulomatosis: Strawberry
Gums of the Oral Cavity Proceedings of Singapore
Healthcare Volume 21 Number 1  2012.
44. Langford CA: Wegener’s Granulomatosis Current
and upcoming therapies, Arthritis Res Ther 5:180191, 2003.
45. Orlowski JP, Clough JD, Dyment PG: Wegener’s
Granulomatosis in the pediatric age group.
Pediatrics, 61(1):83-90, Jan 1978.
46. Cohen RE, Cardoza TT, Drinnan AJ, et al :Gingival
manifestation of wegener’s Granulomatosis, J
Periodontol 61:705, 1999.
47. Wiebe CB, Petricca G, and Larjava HS: Kindler
Syndrome and Periodontal Disease: Review of the
Literature and a 12-Year Follow-Up Case.J
Periodontol. May 2008; 79(5): 961–966.
48. Ricketts DN, Morgan CL, McGregor JM, et al:
Kindler syndrome: a rare cause of desquamative
lesions of the gingiva, Oral Surg Oral Med Oral
Pathol Oral RadiolEndod 84:488, 1997.